Healthcare Provider Details

I. General information

NPI: 1255479267
Provider Name (Legal Business Name): GAVIN RANDALL HITCHINS B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 FOX DR
CHAMPAIGN IL
61820-7236
US

IV. Provider business mailing address

204 S DRAPER AVE
CHAMPAIGN IL
61821-3140
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-8080
  • Fax: 217-398-0172
Mailing address:
  • Phone: 217-359-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: